Wiki fracture care

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richelle25

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Good Morning,

We have an issue that has come up and I am hoping somebody can shed some light on this problem. We have an insurance company recouping 5 years worth of payments on fracture care. The reason for the recoup is that the insurance company is stating that we should have filed only an office visit w/ 55 modifier. Apparently the emergency room where the patient was referred to our office, has been charging for the fractrue code. Understand, that the ER did not do follow up care, casting or any additional treatment. I am looking for information regarding who is correct in charging fracture care.

Thank you
Sherry
 
55 cannot be appended to the E&M but you should have billed the fx care code with the 55 modifier and that is true if the ER billed fx care.
 
thank you for your response, maybe i should re-phrase what I said, they are stating we should have charged only post -operative care for the fracture. We did not do just post- operative care. We applied the first casting and all follow up care.
 
It depends on what the ER charged. If the ER chareger a fx care code then you cannot charge that again. You can charge only a casting or fx aftercare. Even if you applied the first cast. You may need to check with the coders/billers at the facility. It will come down to what they documented was done and if it was coded correctly. Mostly dependent on the type of fx. If is is non displaced then the ER can usually apply a cast or a splint as definitive fx treatment and send them to you for follow up. They have met all requirements for fx care. If it is a displaced fx and they do no reducxtion/manipulation and only stabilize and send to you for tx then they have not met all the requirements for fx care.
 
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With ICD-10 CM you will use a 7th character to indicate initial or susequent care. IF the ER has performed all that is required and sends the patient to you for follow up you will use the 7th character for subsequent encounter. If the ER profides comfort for a fx they cannot reduce and sends the patient to you for fx care then you will use the 7th character for initial. Maybe the ICD-10 Codes will help with this a bit.
 
I understand what you are saying, I am just confused on how an ED can charge for fx when they are not doing any post op care.. everything I am reading is saying that "morally" the ED should not charge for fx if all they did is a sling.. just wish I could find something in "writing".... thank you!
 
While you may be correct on the moral issue it is allowable for them to charge for the fx care if they perform all the elements. Most of the time they do not charge for the post op they append a 54 modifier which is for the actual fx only the post op is then left for you to bill using the same fx care code with the 55 modifier. This is how the system works. So it is possible the isurance company is correct on this one.
 
Actually in regards to ICD-10, the guidelines state "Initial vs subsequent encounter for fractures: Traumatic fractures are coded using the appropriate 7th charcater extension for initial encounter (A,B,C) while the patient is receiving active treatment for the fracture. Examples of active treatment are:surgical treatment, emergencydepartment encounter, and evaluation and treatment by a new physician......" So, you would use the initial code for the first visit where your doctors treat the patient no matter where else that patient has been treated.

The instructions for Application of Casts and Strappings would seem to preclude the ER from charging fracture treatment unless they did something definitive (such as a closed reduction). These instructions state that if an individual who is applying the first cast/splint also assumes all of the responsibility for the subsequent care they cannot use the cast/strapping codes since the initial cast is included in the fracture care code. Since the ER docs are not assuming subsequent care they should be coding an E/M along with the casting codes.

You should definitely follow up on this with your facility. They may have been coding incorerctly Read the guidelines in both ICD and CPT then go back to the insurance comapny with your response.
 
it is evaluation and treatment by a new physician not any encounter with a new physician. If you look under susequent it clearly identifies a cast change etc as a subsequent encounter. It has to do with the patient's injury not your provider. It does not matter if this is the first encounter with your provider rather whether this is the first encounter to have the injury treated. If the injury was definitively treated in the ER then the follow up with the ortho is Subsequent regardless of whther they decide to change the cast etc. If the injury could not be treated in the ER say due to swelling at the injury site so they ice it and immobilize it.. in this case the injury has not been treated so the ortho that next sees the patient is providing initial treatment for the injury. Do not make the mistake of thinking all first visits to your doctor are automatically initial with regards to injuries.
 
Let's agree to disagree on this, even ICD 9 guidelines say to use the traumatic fracture code (as oppsed to aftercare V54.x) for active treatment of the fracture and both give the example of "evaluation and treatment by a new physician. A cast change by a new physician would most certainly be evaluation and treatment. The physician is going to examine and evaluate the patient prior to changing the cast. What I was trying to point out was that since the ER physcian is not assuimg care for the follow-up of trhe fracture they should not be coding for fracture treatment unless they are doing a reduction (whichis a definitive treaqtment). The CPT guidelines state that tthe "listed procedures apply when the cast application or strapping is a replacement procedure used during or after the periood of follow-up care or, when the cast application or strapping is an initial service performed without a restorative treatment or procedure(s) to stabilize or protect a fracture , injury or dislocation and/or to afford comfort to a patient. Restorative treatment or procedure(s) rendered by another individual following the application of the initial cast/strap.splint may be reported with a treatment of fracture and or dislocation code."

In the majority of cases the ER doc is only stabilizing a fracture and is not providing restorative treatment so they should not be coding for fracture care. And in most of the ERs I've had to deal with they call in the Ortho to provide any other treatment. So my point was don't assume the facility is coding correctly. Check the records and challenge them if you have to.
 
sorry I cannot agree.. in the ICD-10 guidelines it clearly states as an example of subsequent care, cast change.
The ER is allowed to charge fx care as long as they meet all the criteria for the fx care, if hey do not intend to provide the follwup, then they bill with the 54 modifier allowing the ortho practice to use the 55 modifier. As I indicated earlier if the fx is non displaced then the ER is able to provide sufficient treatment to satisfy all requirements. It does not matter that your provider will replace the cast, the ER already provided definitive care making your visit subsequent or follow up.
I am saying do not assume the Facility is wrong either.
Coding Clinics also state for ICD-9 Cm that after initial treatment of the injury the acute fx code is not to be reported, you are to use the V54 code for healing fx.
 
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